STATE OF CALIFORNIA SCHEDULE 7 PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 Provider No: ZZT30107G PROFESSIONAL SERVICE COST CENTERS 40.00 Anesthesiology $ 0 $ 0 0.000000 $ $ 0 41.00 Radiology - Diagnostic 0 0 0.000000 0 43.00 Radioisotope 0 0 0.000000 0 44.00 Laboratory 0 0 0.000000 0 53.00 Electrocardiology 0 0 0.000000 0 54.00 Electroencephalography 0 0 0.000000 0 61.00 Emergency 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3) COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED REMUNERATION HBP TOTAL CHARGES TO ALL PATIENTS MEDI-CAL MEDI-CAL COST RATIO OF REMUNERATION CHARGES (Adj ) (Adj ) (Adj ) PHYSICIAN'S REMUNERATION TO CHARGES This is trial version www.adultpdf.com STATE OF CALIFORNIA DPNF SCH 1 Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 Provider No: LTC55256H REPORTED AUDITED DIFFERENCE COMPUTATION OF DISTINCT PART (DP) NURSING FACILITY PER DIEM 1. Distinct Part Ancillary Cost (DPNF Sch 3) $ 0 $ 0 $ 0 2. Distinct Part Routine Cost (DPNF Sch 2) $ 0 $ 10,927,168 $ 10,927,168 3. Total Distinct Part Facility Cost (Lines 1 & 2) $ 0 $ 10,927,168 $ 10,927,168 4. Total Distinct Part Patient Days (Adj 24) 30,806 30,973 167 5. Average DP Per Diem Cost (Line 3 / Line 4) $ 0.00 $ 352.80 $ 352.80 DPNF OVERPAYMENT AND OVERBILLINGS 6. Medi-Cal Overpayments (Adj ) $ 0 $ 0 $ 0 7. Medi-Cal Credit Balances (Adj ) $ 0 $ 0 $ 0 8. MEDI-CAL SETTLEMENT Due Provider (State) $ 0 $ 0 $ 0 (To Summary of Findings) GENERAL INFORMATION 9. Total Available Distinct Part Beds (C/R, W/S S-3) 95 95 0 10. Total Licensed Capacity (All levels) (Adj ) 262 262 0 11. Total Medi-Cal DP Patient Days (Adj ) 0 0 0 CAPITAL RELATED COST 12. Direct Capital Related Cost N/A $ 0 N/A 13. Indirect Capital Related Cost (DPNF Sch 5) N/A $ 473,245 N/A 14. Total Capital Related Cost (Lines 12 & 13) N/A $ 473,245 N/A TOTAL SALARY & BENEFITS 15. Direct Salary & Benefits Expenses N/A $ 4,382,428 N/A 16. Allocated Salary & Benefits (DPNF Sch 5) N/A $ 3,487,661 N/A 17. Total Salary & Benefits Expenses (Lines 15 & 16) N/A $ 7,870,089 N/A COMPUTATION OF DISTINCT PART NURSING FACILITY PER DIEM This is trial version www.adultpdf.com STATE OF CALIFORNIA DPNF SCH 2 Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 Provider No: LTC55256H COST CENTER COL. DIRECT AND ALLOCATED EXPENSE 0.00 Distinct Part $ $ 4,699,183 $ 4,699,183 1.00 Old Cap Rel Costs-Bldg & Fixtures 0 0 2.00 Old Cap Rel Costs-Movable Equipment 0 0 3.00 New Cap Rel Costs-Bldg & Fixtures 155,201 155,201 4.00 New Cap Rel Costs-Movable Equipment 40,800 40,800 4.01 00 4.02 00 4.03 00 4.04 00 4.05 00 4.06 00 4.07 00 4.08 00 5.00 Employee Benefits 1,357,554 1,357,554 6.01 Non-Patient Telephones 0 0 6.02 Data Processing 0 0 6.03 Purchasing/Receiving 0 0 6.04 Patient Admitting 0 0 6.05 Patient Business Office 0 0 6.06 00 6.07 00 6.08 00 6.00 Administrative and General 1,342,245 1,342,245 7.00 Maintenance and Repairs 509,764 509,764 8.00 Operation of Plant 241,805 241,805 9.00 Laundry and Linen Service 235,340 235,340 10.00 Housekeeping 260,684 260,684 11.00 Dietary 1,134,552 1,134,552 12.00 Cafeteria 263,783 263,783 13.00 Maintenance of Personnel 0 0 14.00 Nursing Administration 637,383 637,383 15.00 Central Services & Supply 5,760 5,760 16.00 Pharmacy 0 0 17.00 Medical Records and Library 43,114 43,114 18.00 Social Service 0 0 19.00 00 19.02 00 19.03 00 20.00 00 21.00 Nursing School 0 0 22.00 Intern & Res Service-Salary & Fringes 0 0 23.00 Intern & Res Other Program 0 0 24.00 Paramedical Ed Program 0 0 TOTAL DIRECT AND 101.00 ALLOCATED EXPENSES $ 0 $ 10,927,168 $ 10,927,168 (To DPNF Sch 1) * From Schedule 8, Part I, line 34 plus line 35. REPORTED * AUDITED * SUMMARY OF DISTINCT PART FACILITY EXPENSES DIFFERENCE This is trial version www.adultpdf.com STATE OF CALIFORNIA DPNF SCH 3 Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 Provider No: LTC55256H RATIO COST TO CHARGES ANCILLARY COST CENTERS (From DPNF Sch 4) 49.00 Respiratory Therapy $ 3,502,159 $ 8,505,764 0.411739 $ 0 $ 0 55.00 Med Supply Charged to Patients 9,262,668 35,024,732 0.264461 0 0 56.00 Drugs Charged to Patients 8,084,628 79,938,761 0.101135 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 101.00 TOTAL $ 20,849,455 $ 123,469,257 $ 0 $ 0 (To DPNF Sch 1) * From Schedule 8, Column 27. ** Total Distinct Part Ancillar y Char g es included in the rat e *** Total Distinct Part Ancillary Costs included in the rate. SCHEDULE OF TOTAL DISTINCT PART ANCILLARY COSTS TOTAL ANCILLARY CHARGES TOTAL ANCILLARY TOTAL COST * COST*** TOTAL ANCILLARY CHARGES ** DP ANCILLARY This is trial version www.adultpdf.com STATE OF CALIFORNIA DPNF SCH 4 Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 Provider No: LTC55256H ANCILLARY CHARGES 49.00 Respiratory Therapy $ $ $ 0 55.00 Med Supply Charged to Patients 0 56.00 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 TOTAL DP ANCILLARY CHARGES $ 0 $ 0 $ 0 (To DPNF Sch 3) ADJUSTMENTS (Adj ) ADJUSTMENTS TO TOTAL DISTINCT PART ANCILLARY CHARGES AUDITEDREPORTED This is trial version www.adultpdf.com STATE OF CALIFORNIA DPNF SCH 5 Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 Provider No: LTC55256H COL. COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures $ 0 $ N/A 2.00 Old Cap Rel Costs-Movable Equipment 0 N/A 3.00 New Cap Rel Costs-Bldg & Fixtures 155,201 N/A 4.00 New Cap Rel Costs-Movable Equipment 40,800 N/A 4.01 0N/A 4.02 0N/A 4.03 0N/A 4.04 0N/A 4.05 0N/A 4.06 0N/A 4.07 0N/A 4.08 0N/A 5.00 Employee Benefits 3,502 1,354,052 6.01 Non-Patient Telephones 0 0 6.02 Data Processing 0 0 6.03 Purchasing/Receiving 0 0 6.04 Patient Admitting 0 0 6.05 Patient Business Office 0 0 6.06 00 6.07 00 6.08 00 6.00 Administrative and General 134,772 660,815 7.00 Maintenance and Repairs 39,107 156,378 8.00 Operation of Plant 7,075 89,188 9.00 Laundry and Linen Service 8,611 47,248 10.00 Housekeeping 6,234 147,154 11.00 Dietary 44,957 367,762 12.00 Cafeteria 14,015 95,625 13.00 Maintenance of Personnel 0 0 14.00 Nursing Administration 15,687 537,179 15.00 Central Services & Supply 669 2,958 16.00 Pharmacy 0 0 17.00 Medical Records and Library 2,616 29,300 18.00 Social Service 0 0 19.00 00 19.02 00 19.03 00 20.00 00 21.00 Nursing School 0 0 22.00 Intern & Res Service-Salary & Fringes 0 0 23.00 Intern & Res Other Program 0 0 24.00 Paramedical Ed Program 0 0 101 TOTAL ALLOCATED INDIRECT EXPENSES $ 473,245 $ 3,487,661 * These amounts include both Skilled Nursing Facility expenses, (To DPNF SCH 1) line 34 and Nursing Facility expenses, line 35. (COL 1) EMP BENEFITS * (COL 2) RELATED * ALLOCATION OF INDIRECT EXPENSES DISTINCT PART NURSING FACILITY AUDITED CAP AUDITED SAL & This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 8 Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG & MOVABLE BLDG & MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 0.00 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 COMPUTATION OF COST ALLOCATION (W/S B) GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures 0 2.00 Old Cap Rel Costs-Movable Equipmen 0 0 3.00 New Cap Rel Costs-Bldg & Fixtures 4,459,793 0 0 4.00 New Cap Rel Costs-Movable Equipme 6,975,938 0 0 0 4.01 0 0 0 0 0 4.02 0 0 0 0 0 0 4.03 0 0 0 0 0 0 0 4.04 0 0 0 0 0 0 0 0 4.05 0 0 0 0 0 0 0 0 0 4.06 0 0 0 0 0 0 0 0 0 0 4.07 0 0 0 0 0 0 0 0 0 0 0 4.08 0 0 0 0 0 0 0 0 0 0 0 0 5.00 Employee Benefits 22,740,100 0 0 49,864 8,950 0 0 0 0 0 0 0 6.01 Non-Patient Telephones 0 0 0 0 0 0 0 0 0 0 0 0 6.02 Data Processing 0 0 0 0 0 0 0 0 0 0 0 0 6.03 Purchasing/Receiving 0 0 0 0 0 0 0 0 0 0 0 0 6.04 Patient Admitting 0 0 0 0 0 0 0 0 0 0 0 0 6.05 Patient Business Office 0 0 0 0 0 0 0 0 0 0 0 0 6.06 0 0 0 0 0 0 0 0 0 0 0 0 6.07 0 0 0 0 0 0 0 0 0 0 0 0 6.08 0 0 0 0 0 0 0 0 0 0 0 0 6.00 Administrative and General 23,093,189 0 0 2,093,674 857,361 0 0 0 0 0 0 0 7.00 Maintenance and Repairs 4,854,205 0 0 240,220 160,666 0 0 0 0 0 0 0 8.00 Operation of Plant 2,408,602 0 0 1,583 35,078 0 0 0 0 0 0 0 9.00 Laundry and Linen Service 886,908 0 0 19,011 0 0 0 0 0 0 0 0 10.00 Housekeeping 2,165,800 0 0 14,672 733 0 0 0 0 0 0 0 11.00 Dietary 1,403,139 0 0 30,292 8,071 0 0 0 0 0 0 0 12.00 Cafeteria 1,475,863 0 0 62,068 10,297 0 0 0 0 0 0 0 13.00 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 14.00 Nursing Administration 1,806,659 0 0 11,656 2,865 0 0 0 0 0 0 0 15.00 Central Services & Supply 401,519 0 0 56,222 47,8570000000 16.00 Pharmacy 2,395,762 0 0 23,498 139,2610000000 17.00 Medical Records and Library 1,132,829 0 0 27,350 51,1920000000 18.00 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 19.00 0 0 0 0 0 0 0 0 0 0 0 0 19.02 0 0 0 0 0 0 0 0 0 0 0 0 19.03 0 0 0 0 0 0 0 0 0 0 0 0 20.00 000000000000 21.00 Nursing School 000000000000 22.00 Intern & Res Service-Salary & Fringes 0 0 0 0 0 0 0 0 0 0 0 0 23.00Intern & Res Other Program 000000000000 24.00Paramedical Ed Program 000000000000 INPATIENT ROUTINE COST CENTERS 25.00 Adults & Pediatrics (Gen Routine) 13,625,389 0 0 306,763 525,125 0 0 0 0 0 0 0 26.00 Intensive Care Unit 3,413,530 0 0 57,830 177,4120000000 27.00 Coronary Care Unit 000000000000 28.00 Neonatal Intensive Care Unit 000000000000 29.00Surgical Intensive Care 000000000000 30.00 Subprovider I 000000000000 31.00 Subprovider II 000000000000 32.00 000000000000 33.00 Nursery 1,479,069 0 0 21,030 18,9760000000 34.00 Medicare Certified Nursing Facility 4,699,183 0 0 155,201 40,800 0 0 0 0 0 0 0 35.00 Distinct Part Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 36.00 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 36.01 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 36.02 Transitional Care Unit 000000000000 This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 8 Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG & MOVABLE BLDG & MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 0.00 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 COMPUTATION OF COST ALLOCATION (W/S B) ANCILLARY COST CENTERS 37.00 Operating Room 4,910,229 0 0 263,456 514,869 0 0 0 0 0 0 0 37.01 Gastro Intestinal Service 211,921 0 0 10,920 9,749 0 0 0 0 0 0 0 37.20 Cardicac Cath Lab 1,096,026 0 0 8,427 560,950 0 0 0 0 0 0 0 38.00 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 39.00 Delivery Room and Labor Room 4,096,133 0 0 70,607 130,6540000000 40.00 Anesthesiology 135,499 0 0 760 58,4330000000 41.00 Radiology - Diagnostic 3,316,761 0 0 102,608 1,687,480 0 0 0 0 0 0 0 41.01 CT Scan and MRI 513,844 0 0 4,625 745,294 0 0 0 0 0 0 0 43.00 Radioisotope 1,287,006 0 0 4,986 7,7570000000 44.00 Laboratory 5,128,126 0 0 53,728 111,3240000000 44.01Pathological Lab 000000000000 46.00 Whole Blood & Packed Red Blood 1,555,570 0 0 2,605 1,6170000000 47.00 Blood Storing and Processing 000000000000 48.00 Intravenous Therapy 103,85500000000000 49.00 Respiratory Therapy 1,854,924 0 0 70,109 52,7220000000 50.00 Physical Therapy 1,686,892 0 0 43,768 12,183 0 0 0 0 0 0 0 51.00 Occupational Therapy 655,034 0 0 19,048 1,907 0 0 0 0 0 0 0 52.00 Speech Pathology 000000000000 53.00 Electrocardiology 1,089,607 0 0 77,376 88,9110000000 54.00 Electroencephalography 63,2190008,7940000000 55.00 Medical Supplies Charged to Patients 6,784,187000460,3500000000 55.01 Medical Supplies Chrg. Pat. - IMP 8,335,66300000000000 56.00 Drugs Charged to Patients 3,702,317 0 0 0 8,466 0 0 0 0 0 0 0 57.00 Renal Dialysis 290,292 0 0 3,441 0 0 0 0 0 0 0 0 58.00ASC (Non-Distinct Part) 000000000000 59.00 Ultrasound 339,981 0 0 2,506 84,2290000000 59.02 000000000000 59.03 000000000000 60.00 Clinic 504,077 0 0 116,420 4,1020000000 60.01 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 61.00 Emergency 5,209,925 0 0 161,597 69,537 0 0 0 0 0 0 0 62.00Observation Beds 000000000000 71.00 Home Health Agency 10,130,828 0 0 105,213 85,1030000000 89.00 Utilization Review 0000166,7580000000 93.00 Hospice 2,138,604 0 0 61,58200000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 000000000000 97.00Research 000000000000 98.00Physicians' Private Office 000000000000 99.00 Nonpaid Workers 000000000000 99.01 0 0 0 0 0 0 0 0 0 0 0 0 99.02 0 0 0 0 0 0 0 0 0 0 0 0 99.03 000000000000 99.04 000000000000 99.05 000000000000 100.00 000000000000 100.01 Foundation 0 0 0 49,86400000000 100.02 000000000000 100.03 Community Relations 2,245,202 0 0 55,212 20,104 0 0 0 0 0 0 0 100.04 000000000000 TOTAL 166,803,199 0 0 4,459,793 6,975,938 0 0 0 0 0 0 0 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: MARIAN MEDICAL CENTER TRIAL BALANCE EXPENSES GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures 2.00 Old Cap Rel Costs-Movable Equipmen 3.00 New Cap Rel Costs-Bldg & Fixtures 4.00 New Cap Rel Costs-Movable Equipme 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 Employee Benefits 6.01 Non-Patient Telephones 6.02 Data Processing 6.03 Purchasing/Receiving 6.04 Patient Admitting 6.05 Patient Business Office 6.06 6.07 6.08 6.00 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 11.00 Dietary 12.00 Cafeteria 13.00 Maintenance of Personnel 14.00 Nursing Administration 15.00 Central Services & Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 19.00 19.02 19.03 20.00 21.00 Nursing School 22.00 Intern & Res Service-Salary & Fringes 23.00 Intern & Res Other Program 24.00 Paramedical Ed Program INPATIENT ROUTINE COST CENTE 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 Neonatal Intensive Care Unit 29.00 Surgical Intensive Care 30.00 Subprovider I 31.00 Subprovider II 32.00 33.00 Nursery 34.00 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 Adult Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit SCHEDULE 8.1 Fiscal Period Ended: JUNE 30, 2009 ADMINIS- ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE & COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 COMPUTATION OF COST ALLOCATION (W/S B) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3,434,543 0 0 0 0 0 0 0 0 29,478,767 0 354,353 0 0 0 0 0 0 0 0 5,609,443 1,204,152 0 215,566 0 0 0 0 0 0 0 0 2,660,829 571,187 0 27,788 0 0 0 0 0 0 0 0 933,707 200,434 0 351,643 0 0 0 0 0 0 0 0 2,532,849 543,714 0 102,249 0 0 0 0 0 0 0 0 1,543,751 331,390 0 130,511 0 0 0 0 0 0 0 0 1,678,739 360,367 0 0 0 0 0 0 0 0 0 0 0 0 0 524,187 0 0 0 0 0 0 0 0 2,345,366 503,468 092,11100000000597,708 128,307 0 785,819000000003,344,340 717,913 0 269,177000000001,480,548 317,822 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 0000000000 00 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 0000000000 00 0 3,914,058 0 0 0 0 0 0 0 0 18,371,335 3,943,685 0 927,150000000004,575,922 982,291 0000000000 00 0000000000 00 0000000000 00 0000000000 00 0000000000 00 0000000000 00 0 277,748000000001,796,823 385,715 0 1,357,554 0 0 0 0 0 0 0 0 6,252,739 1,342,245 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: MARIAN MEDICAL CENTER TRIAL BALANCE EXPENSES ANCILLARY COST CENTERS 37.00 Operating Room 37.01 Gastro Intestinal Service 37.20 Cardicac Cath Lab 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 CT Scan and MRI 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood & Packed Red Blood 47.00 Blood Storing and Processing 48.00 Intravenous Therapy 49.00 Respiratory Therapy 50.00 Physical Therapy 51.00 Occupational Therapy 52.00 Speech Pathology 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 55.01 Medical Supplies Chrg. Pat. - IMP 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 Ultrasound 59.02 59.03 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 Home Health Agency 89.00 Utilization Review 93.00 Hospice NONREIMBURSABLE COST CENTE 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 99.02 99.03 99.04 99.05 100.00 100.01 Foundation 100.02 100.03 Community Relations 100.04 TOTAL SCHEDULE 8.1 Fiscal Period Ended: JUNE 30, 2009 ADMINIS- ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE & COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 COMPUTATION OF COST ALLOCATION (W/S B) 0 1,151,502 0 0 0 0 0 0 0 0 6,840,056 1,468,321 0 61,087 0 0 0 0 0 0 0 0 293,678 63,042 0 312,737 0 0 0 0 0 0 0 0 1,978,140 424,638 0 0 0 0 0 0 0 0 0 0 0 0 0 929,925000000005,227,319 1,122,123 0000000000194,692 41,794 0 899,698 0 0 0 0 0 0 0 0 6,006,546 1,289,396 0 146,569 0 0 0 0 0 0 0 0 1,410,332 302,749 077,051000000001,376,800 295,551 0 857,677000000006,150,856 1,320,374 0000000000 00 00000000001,559,793 334,833 0000000000 00 031,82200000000135,677 29,125 0 462,670000000002,440,425 523,874 0 268,363 0 0 0 0 0 0 0 0 2,011,206 431,736 0 190,364 0 0 0 0 0 0 0 0 866,353 185,976 0000000000 00 0 318,317000000001,574,211 337,928 019,5770000000091,59019,661 00000000007,244,537 1,555,149 00000000008,335,663 1,789,376 0 0 0 0 0 0 0 0 0 0 3,710,783 796,576 0 0 0 0 0 0 0 0 0 0 293,733 63,054 0000000000 00 0 104,99400000000531,710 114,140 0000000000 00 0000000000 00 0 140,62400000000765,223 164,267 0 0 0 0 0 0 0 0 0 0 0 0 0 1,344,785 0 0 0 0 0 0 0 0 6,785,843 1,456,684 0000000000 00 0 2,054,5730000000012,375,717 2,656,635 0 474,61900000000641,377 137,681 00000000002,200,186 472,303 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 0000000000 00 0000000000 00 0000000000 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 0000000000 00 0000000000 00 0000000000 00 000000000049,86410,704 0000000000 00 0 187,503 0 0 0 0 0 0 0 0 2,508,020 538,385 0000000000 00 0 22,798,914 0 0 0 0 0 0 0 0 166,803,199 29,478,767 This is trial version www.adultpdf.com . 523, 874 0 268,363 0 0 0 0 0 0 0 0 2,011,206 431 ,73 6 0 190,364 0 0 0 0 0 0 0 0 866,353 185, 976 0000000000 00 0 318,3 170 00000001, 574 ,211 3 37, 928 019, 577 0000000091,59019,661 000000000 07, 244,5 37 1,555,149 00000000008,335,663 1 ,78 9, 376 0 0 0 0 0 0 0 0 0 0 3 ,71 0 ,78 3 79 6, 576 0 0 0 0 0 0 0 0 0 0 293 ,73 3 63,054 0000000000. TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3) COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED REMUNERATION HBP TOTAL CHARGES TO ALL PATIENTS MEDI-CAL MEDI-CAL COST RATIO OF REMUNERATION CHARGES (Adj. B) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3,434,543 0 0 0 0 0 0 0 0 29, 478 ,76 7 0 354,353 0 0 0 0 0 0 0 0 5,609,443 1,204,152 0 215,566 0 0 0 0 0 0 0 0 2,660,829 571 ,1 87 0 27, 788 0 0 0 0 0 0 0 0 933 ,70 7 200,434 0 351,643 0 0 0 0 0 0 0 0 2,532,849 543 ,71 4 0 102,249 0 0 0 0 0 0 0 0 1,543 ,75 1 331,390 0 130,511 0 0 0 0 0 0 0 0 1, 678 ,73 9 360,3 67 0 0 0 0 0 0 0 0 0 0 0 0 0 524,1 87 0 0 0 0 0 0 0 0 2,345,366 503,468 092,111000000005 97, 708